DOI: 10.1111/tog.
12630 2020;22:57–68
The Obstetrician & Gynaecologist
http://onlinetog.org
The role of frozen–thawed embryo replacement cycles
in assisted conception
a b,c
Matt Noble MBChB BSc (MedSci) Hons MRCOG,* Tim Child
a
Clinical Research Fellow, Oxford Fertility, Institute for Reproductive Sciences, Oxford OX4 2HW, UK
b
Associate Professor, Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford OX3 9DU, UK
c
Medical Director, Oxford Fertility, The Fertility Partnership, Institute for Reproductive Sciences, Oxford OX4 2HW, UK
*Correspondence: Matt Noble. Email: mattnoble@doctors.org.uk
Accepted on 25 June 2019. Published online 16 December 2019.
Key content
 Recent years have seen a dramatic rise in the number of frozen–
thawed embryo replacement (FER) cycles.
 Improved embryo cryopreservation techniques have resulted in
outcomes for FER that are similar to fresh embryo transfer.
 FER maximises the cumulative live-birth rate of a fresh in vitro
fertilisation (IVF) cycle by using excess embryos and encourages a
policy of single embryo transfer; this has contributed to a fall in
the multiple pregnancy rate associated with IVF.
 Freezing all suitable embryos in a fresh cycle reduces the risk of
ovarian hyperstimulation syndrome.
 The endometrium is prepared for FER by a natural or medicated
protocol; the optimum method is unknown.
Learning objectives
 To appreciate the importance of FER in IVF practice.
Please cite this paper as: Noble M, Child T. The role of frozen–thawed embryo replacement cycles in assisted conception. The Obstetrician & Gynaecologist
2020;22:57–68. https://doi.org/10.1111/tog.12630
Introduction
In the early days of in vitro fertilisation (IVF), embryos were
created through fertilisation of one or two eggs collected in a
natural cycle and pregnancy rates were low.1 With the
introduction of ovarian stimulation, the number of embryos
available to transfer in each fresh cycle increased.
Consequently, the transfer of multiple embryos was
common and those that were not transferred were
discarded. In 1983, a solution was proposed when
Trounsen and Mohr2 described the first pregnancy from a
cryopreserved embryo, with the first baby born after frozen–
thawed embryo replacement (FER) the following year.3
For many years FER was associated with much lower
embryo survival and live-birth rates than fresh IVF. However,
recent advances in embryology and a better understanding of
how to prepare the endometrium for FER have led to
improved outcomes.4,5 Data from the Human Fertilisation
and Embryology Authority6 suggest the UK live-birth rate for
ª 2019 Royal College of Obstetricians and Gynaecologists
Review
MA MD MRCOG
 To understand the current debate surrounding fresh versus
frozen IVF.
 To understand the indications for, and methods of,
embryo cryopreservation.
 To understand the commonly used methods of endometrial
preparation for FER.
 To be able to date an FER pregnancy.
Ethical issues

Funding from the National Health Service (NHS) for embryo
storage and FER varies widely across the UK; where funding is
limited, this can result in viable embryos being discarded.
 When an embryo is created by a couple, the consent of both
partners is required before transferring the embryo.
Keywords: assisted reproductive technology / frozen–thawed
embryo replacement / in vitro fertilisation
FER is now similar to that of fresh IVF (Figure 1). However,
the data may be biased in favour of FER, as only good-quality
embryos from those with the best prognosis are
cryopreserved, whereas poor-quality embryos are often
transferred in fresh cycles. Consequently, debate continues
regarding whether fresh or frozen embryo transfer results in
better outcomes.
The improvement in outcomes associated with FER has
been mirrored by a dramatic increase in the number of FER
cycles. Between 2012 and 2017, the number of FER cycles
undertaken in the UK rose from 11 959 to 23 828 – an
increase of 99% – while the total number of fresh cycles
declined by 5% (Figure 2). Frozen cycles now account for
more than 34% of all cycles.6
The objectives of this Review are to highlight the
importance of FER in assisted reproduction; outline the
methods of, and indications for, embryo cryopreservation;
and discuss the various methods of preparing the
endometrium for FER.
57
 Frozen–thawed embryo replacement
Rate (%)
Year
Multiple pregnancy rate per IVF birth (all IVF cycles)
Fresh cycles – live-birth rate per embryo transferred
Frozen cycles – live-birth rate per embryo transferred
Figure 1. Live-birth rate per embryo transferred and multiple birth rate per live birth (UK). Constructed using Human Fertilisation and Embryology
Authority data.6 IVF = in vitro fertilisation.
Reasons for the increase in frozen–thawed
embryo replacement
Improved embryology techniques
The aim of embryo cryopreservation is to preserve the
embryo in a state of suspended animation. Freezing the
embryo increases the viscosity of the intracellular and
extracellular environments, stopping biochemical
processes.7 However, freezing results in the formation of ice
crystals and a rise in salt concentration around the ice, which
can damage the embryo.8 This situation is ameliorated
through the use of cryoprotectants, which dehydrate the
embryo and prevent ice formation. Cryoprotectants fall into
two categories: permeating and non-permeating. Permeating
cryoprotectants permeate the cell membrane, driving water
out of the cell. Non-permeating cryoprotectants encourage
water out through osmosis.
Initial embryo cryopreservation strategies focused on slow
freezing. This involves dehydration of the embryo, achieved
by passing it through a series of low concentration
cryoprotectants, followed by a controlled freezing process,
which takes around 2 hours and requires a cryo machine.
Many IVF units now use a freezing technique known as
vitrification. Vitrification is faster and more convenient,
taking only minutes and not requiring large, expensive
machinery. During vitrification, the embryo is exposed to
high concentrations of cryoprotectants and cooled rapidly by
exposing it directly or indirectly to liquid nitrogen. The
rapidity of the cooling process prevents water from forming
58
ice crystals, effectively solidifying the cells into a glass-like
state and avoiding cellular damage.9
Several studies have highlighted higher embryo survival
rates following vitrification compared with slow freezing.4,10
This translates into improved clinical outcomes, with a 2015
randomised controlled trial (RCT)11 demonstrating a higher
live-birth rate per embryo thawed after vitrification
compared with slow freezing. Moreover, a cohort study of
more than 30 000 FERs12 demonstrated a higher live-birth
rate per cycle started for vitrified versus slow frozen embryos,
with meta-analysis data13 supporting these findings. The
simplicity, speed and high embryo survival rate (more than
95% post-thaw survival) offered by vitrification have led to
its widespread uptake into clinical practice.
Embryos can be cryopreserved at any stage of development
from the pronuclear (day 1) and cleavage (days 2–4) stages to
blastocyst (days 5 and 6).14 During culture, embryos are
inspected at different timepoints, with the number of viable
embryos falling over time, as some stop developing. This
‘embryonic arrest’ may be due to chromosomal abnormalities,
oxidative stress or inability to activate specific genes.
Postponing cryopreservation until blastocyst allows
embryos to be observed for longer, to better determine
which are viable and avoid freezing embryos unnecessarily.
Several studies have demonstrated improved live-birth rates
following transfer of embryos cryopreserved at the blastocyst
stage compared with embryos at earlier stages.7,15,16 We have
undertaken a UK-wide survey of practice and it is clear that
blastocyst is the preferred stage of embryo freezing in the UK:
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(A)
70 000

60 000

50 000

Number of cycles
40 000

30 000

20 000

10 000

Year

(B)
100
90
80
70
Cycles (%)

60
50
40
30
20
10
0

Year
Fresh cycles Frozen cycles All cycles

Figure 2. Number (A) and proportion (B) of fresh and frozen in vitro fertilisation/intracytoplasmic sperm injection cycles in the UK. Graphs
constructed using Human Fertilisation and Embryology Authority data.6

98% of the responding clinics (77% of UK clinics responded)
favouring cryopreservation at this stage.17
Widening indications for embryo freezing
Many couples who undergo a fresh IVF cycle will have more
than one viable embryo available at the blastocyst stage.
Improved outcomes after embryo cryopreservation and FER
have allowed clinics to move to a policy of elective single
embryo transfer, while maintaining cumulative live-birth
rates.18,19 Recent years have seen a reduction in the multiple
pregnancy rate associated with IVF (Figure 1), with FER
playing a central role in this trend.6
With improved success of embryo cryopreservation, the
indications for embryo freezing have widened. Slow-
developing embryos, which become blastocysts on day 6,
are associated with lower pregnancy rates in fresh cycles than
are day-5 blastocysts.20,21 This may be partly due to the day
of transfer being out of synchrony with the endometrial
window of implantation.20,21 Several studies demonstrate
higher pregnancy rates when day-6 embryos are
cryopreserved and resynchronised with the endometrium in
a subsequent FER cycle compared with fresh transfer
on day 6.22,23
A fresh cycle in which all suitable embryos are frozen is
known as a ‘freeze-all’ or ‘freeze-only’ cycle. Box 1 shows
indications for a freeze-all strategy. Planned freeze-all permits
the use of pre-implantation genetic testing, whereby embryos
are biopsied and cryopreserved while genetic analysis is
undertaken. It also allows for embryo batching when patients
are late in their fertile lives and want more than one child, or
for fertility preservation in those due to undergo gonadotoxic
therapy. It is yet to be proven, but there may also be benefit

ª 2019 Royal College of Obstetricians and Gynaecologists 59

 Frozen–thawed embryo replacement
Box 1. Indications for freezing all suitable embryos (freeze-all strategy)
Acute (unplanned) freeze-all
 Ovarian hyperstimulation syndrome
 Uterine abnormality identified during ovarian stimulation (e.g.
endometrial polyp identified during the cycle, fluid in the
endometrium)
 Complications of egg-collection procedure (e.g. intraperitoneal
bleeding, damage to viscera, pelvic infection)
 Social factors (unable to attend embryo transfer or need to defer
pregnancy)
 Raised progesterone on day of trigger injection (continuing research)
Planned freeze-all
 Pre-implantation genetic testing
 Fertility preservation
 Recurrent implantation failure (continuing research)
to the freeze-all approach in cases of recurrent
implantation failure.24,25
A common reason for an unplanned freeze-all strategy is
ovarian hyperstimulation syndrome (OHSS). If an embryo
implants during a cycle complicated by or at high risk of
OHSS, the resultant rise in human chorionic gonadotrophin
(hCG) is associated with an increase in the inflammatory
mediator vascular endothelial growth factor and a prolonged,
more severe clinical course.26 The freeze-all approach
prevents a rise in hCG, avoiding the development of late
OHSS. A Cochrane meta-analysis27 suggests that if the rate of
OHSS is 7% following fresh transfer, in the freeze-all
approach it is 1–3%. This is clinically significant given the
morbidity associated with the condition. Other acute
indications for freezing all suitable embryos include pelvic
infection, uterine abnormalities (such as fluid in the
endometrium) and social factors. The option of freezing all
suitable embryos with no adverse effect on cumulative live-
birth rate has undoubtedly led to increased flexibility and
more individualised patient care in IVF.
Improved outcomes with a planned freeze-all
strategy?
Some clinicians advocate a freeze-all strategy in all fresh
cycles in an approach known as ‘segmented IVF’.28 It is
postulated that the supraphysiological hormone levels
associated with controlled ovarian stimulation may
adversely affect endometrial receptivity, reducing the
pregnancy rate and impacting perinatal outcomes.29 Indeed,
the histological changes in the endometrium necessary for
implantation occur earlier in controlled ovarian stimulation
than in the natural cycle.30–32 Moreover, controlled ovarian
stimulation may negatively affect the expression of proteins
essential for implantation, such as integrins.28 In theory this
could be corrected by embryo cryopreservation and
subsequent FER. However, this remains controversial.
60
Pregnancy and live-birth rate
Whether the freeze-all strategy improves clinical pregnancy
and live-birth rate compared with fresh embryo transfer in all
patients is debatable. A systematic review and meta-analysis
in 201333 included three RCTs and demonstrated a higher
ongoing pregnancy rate associated with the freeze-all strategy
compared with fresh transfer. However, one of the included
studies was later retracted due to poor methodology, and a
subsequent Cochrane meta-analysis27 found no difference in
live-birth rate between patients undergoing elective freeze-all
versus those undergoing fresh transfer. Moreover, two large
RCTs published in 20185,34 demonstrated no difference in
live-birth rate between the freeze-all approach and fresh
transfer in ovulatory women. These trials excluded patients
with polycystic ovarian syndrome (PCOS), who are a group
considered to be high responders (i.e. those responding
strongly to ovarian stimulation).
In high responders, such as those with high antral follicle
counts and PCOS, the case for the freeze-all strategy appears
stronger. In 2011 an RCT35 demonstrated a significantly
higher ongoing pregnancy rate with the freeze-all approach
compared with fresh transfer in those with a total antral
follicle count of more than 15. This finding was supported by
a 2016 RCT of 1508 women with PCOS,36 which highlighted
a higher live-birth rate with the freeze-all strategy compared
with fresh transfer (relative risk [RR] 1.17, 95% confidence
interval [CI] 1.05–1.31). Moreover, a 2018 analysis of more
than 80 000 cycles from the Society for Assisted
Reproduction Technology database in the USA37 compared
the outcomes of women undergoing their first FER after
freeze-all approach in their first fresh cycle with those
undergoing their first fresh embryo transfer and
demonstrated a higher live-birth rate in high responders
(15 or more oocytes; 52.0% versus 48.9%, P < 0.02) and
a lower live-birth rate in intermediate (6–14 oocytes; 35.3%
versus 41.2%, P < 0.02) and low responders (1–5 oocytes;
11.5% versus 25.9%, P < 0.02) associated with the freeze-all
strategy. However, caution is warranted, as the reason for the
freeze-all approach was poorly documented.
The most recent RCT published in 201938 comparing
the freeze-all strategy with fresh embryo transfer included
1650 women and highlighted a significantly higher live-birth
rate among those in whom the freeze-all strategy was
employed compared with fresh transfer (50% versus 40%;
RR 1.26, 95% CI 1.14–1.41). This study excluded those at risk
of OHSS; therefore, one would expect the number of high
responders to be low. However, closer analysis of the study
reveals that the patient cohort was young (mean age 28 years)
with a relatively high ovarian response. Moreover, the
cumulative live-birth rate associated with embryos derived
from the fresh cycle was no different in the freeze-all and
fresh transfer groups, and the duration to pregnancy was
longer in the freeze-all group. These trends of no difference in
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 Noble and Child

(A) (B)

AH
ZP

(C) (D)

TE

Figure 3. Microscopic (x200 magnification) images of blastocyst embryos during thaw (with consent of patients). (A) A collapsed embryo. At the
time of embryo cryopreservation, embryos are collapsed by disruption of the TE. This is done either mechanically or by laser. The aim of this is to
reduce the water content and avoid ice crystal formation. (B) AH. It is possible that the outer coat of the embryo, the ZP, may become hardened
during cryopreservation. To help the embryo hatch, a portion of the ZP may be removed at the time of thaw using a laser. (C) A thawed and re-
expanded embryo. Embryos are thawed by passing through a series of decreasing concentration cryoprotectants. Expansion of the embryo occurs
over around 1–2 hours. (D) A thawed blastocyst hatching through the ZP. The cross marking in the images is the guide for the laser used for AH.
AH = assisted hatching; TE = trophectoderm; ZP = zona pellucida.

cumulative live-birth rate between the freeze-all strategy and
fresh transfer, and a longer time to pregnancy associated with
the freeze-all approach, are consistent across many of the
published RCTs.5,34,36
There is some evidence that the freeze-all strategy may be
beneficial if there is a premature rise in serum progesterone
level in a fresh IVF cycle.39–41 In fresh IVF a ‘trigger’ injection of
hCG or gonadotrophin-releasing hormone (GnRH) agonist is
administered around 36 hours before oocyte collection to
induce oocyte maturation (mimicking the mid-cycle surge of
luteinising hormone [LH] seen in a natural cycle). It is
postulated that if the serum progesterone is prematurely
elevated on the day of trigger, this may shift the endometrial
window of implantation, causing asynchrony between the
endometrium and the embryo, negatively impacting
implantation. Various thresholds of serum progesterone are
suggested of between 2.9 and 6.4 nmol/ml.41–43 However, more
data are required before the freeze-all approach can be widely
recommended in this situation.
Maternal and perinatal outcomes
A 2018 meta-analysis,44 which included 26 studies, broadly
compared maternal and perinatal outcomes in fresh versus
frozen embryo transfer and concluded that, compared with
fresh embryo transfer, conception through FER conveyed a
lower relative risk of preterm birth (birth before 37 weeks: RR
0.9, 95% CI 0.84–0.97), low birthweight (<2500 g: RR 0.72,
95% CI 0.67–0.77) and small for gestational age (RR 0.61,
95% CI 0.56–0.67). A second systematic review45 supports
these findings. The risk of antepartum haemorrhage,
congenital anomalies, perinatal mortality and admission to
a neonatal unit appeared similar between fresh and frozen
embryo transfer.44,45 However, both meta-analyses
highlighted an increased RR of gestational hypertensive
disorders and postpartum haemorrhage associated with FER.
Interestingly, the most recent RCT38 comparing the freeze-all
strategy with fresh transfer has also demonstrated a higher
rate of pre-eclampsia (by a factor of 3) in the freeze-all group
(RR 3.1, 95% CI 1.06–9.30).

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 Frozen–thawed embryo replacement
Box 2. Characteristics of different methods of endometrial
preparation for frozen–thawed embryo replacement
Natural cycle frozen–thawed embryo replacement
Advantages:
 No need for medication (avoids adverse effects and concordance
issues)
 May be cheaper than medicated frozen–thawed embryo replacement
(FER)
Disadvantages:
 Involves intensive ultrasound and endocrine monitoring
 Requires ovulation
 No control over day of embryo transfer, as fixed according to
ovulation (so embryo transfer may be over a weekend)
 Cancellation rate around 8–15% of started cycles
Medicated frozen–thawed embryo replacement
Advantages:
 Permits embryo transfer in anovulatory women
 Allows choice over day of embryo transfer, which is convenient
 In the case of ‘thin endometrium’, the dose and route of estrogen
can be modified
 Woman may feel more in control of events
 Relatively low cycle cancellation rate (1–2%)
Disadvantages:
 Prolonged course of medication
 Medication may have adverse effects
 More expensive than natural cycle FER
Ovarian stimulation frozen–thawed embryo replacement
Advantages:
 Permits embryo transfer in anovulatory women who do not want
standard medicated FER
 May involve fewer days of medication than standard medicated FER
 Relies on endogenous estradiol, so it may be beneficial in those with
absorption issues
Disadvantages:
 Requires intensive monitoring
 Medication can cause adverse effects (e.g. injection site reactions
or infections)
 Gonadotrophins are associated with a risk of ovarian
hyperstimulation syndrome
 Clomifene may have an adverse effect on the endometrium
 Gonadotrophins are expensive
There is a well-documented association between FER and
large-for-gestational-age babies, with Maheshwari and
colleagues’ meta-analysis44 concluding that the RR of high
birthweight (>4500 g) is 1.85 (95% CI 1.46–2.33) compared
with fresh transfer. Moreover, a 2016 observational study46 of
more than 112 000 singleton pregnancies demonstrated a
higher risk of high birthweight (>4000 g) with FER
compared with fresh IVF. These findings are clinically
significant considering the association of high birthweight
62
with long-term development of the metabolic syndrome and
potentially serious obstetric complications, such as shoulder
dystocia and birth trauma.47 Given the difficulty in predicting
these complications in obstetric practice, obstetricians should
be cognisant of the association between conception through
FER and high birthweight.
The higher birthweight associated with FER is likely
multifactorial. The supraphysiological hormone levels seen in
fresh IVF may affect endometrial function interfering with
placentation and leading to comparatively lighter babies.48
Differences in expression of genes between fresh and frozen–
thawed embryos are also implicated.49 In addition, molecular
studies describe a higher rate of abnormalities of the
intracellular spindle structure necessary for cell division in
frozen–thawed compared with fresh blastocysts, which may
disrupt the normal mechanisms of cellular division.50
Further good-quality RCTs are needed to directly compare
the freeze-all strategy with fresh transfer. One such RCT is the
multicentre E-freeze trial, the results of which are awaited.51
Until the outcome of this and further trials are available, an
individualised approach seems most appropriate, with the
freeze-all strategy reserved for high responders.
Process of frozen–thawed embryo
replacement
Endometrial preparation for frozen–thawed
embryo replacement
The process of embryo thaw and re-expansion takes around
1–2 hours and is described in Figure 3. Before a
cryopreserved embryo can be thawed and transferred, the
endometrium must be prepared, such that it is at its most
receptive. The endometrium can be prepared using four main
methods: the natural cycle, the modified natural cycle,
hormone replacement (medicated FER) or ovarian
stimulation. Despite the recent rise in the number of FERs,
the optimum protocol for preparation of the endometrium is
unknown. Prospective data and meta-analyses undertaken
between 2013 and 2017 indicate little difference in outcome
between each method, but data are limited and protocols
vary between clinics, making conclusions difficult to draw.52–
55
Box 2 summarises the characteristics of different methods
of endometrial preparation.
Natural cycle frozen–thawed embryo replacement
Natural cycle FER involves ultrasound and endocrine
monitoring for signs of ovulation, with embryo transfer
timed accordingly (Figure 4). Following FER, embryo
implantation and development are supported by the
endogenous hormones secreted by the corpus luteum. Given
that ovulation occurs in natural cycle FER, abstinence from
intercourse or barrier contraception is recommended to reduce
the risk of multiple pregnancy through natural conception.
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Natural cycle FER

Endocrine monitoring
E.g. once or twice daily presence of
urinary or serum LH tests corpus luteum

Day 1
Days 9–13 USS Embryo transfer Urinary pregnancy
Dominant follicle AND At day 6 or 7 post-LH surge test 11 days
Endometrial thickness ≥7 mm (blastocyst) after ET
= proceed to endocrine testing

Modified natural cycle FER

Once dominant follicle of 16–20 mm: presence of

Subcutaneous hCG trigger injection corpus luteum

Day 1 Days 9–13 USS Urinary pregnancy

Dominant follicle AND Embryo transfer
At day 6 or 7 post-hCG trigger test 11 days
Endometrial thickness ≥7 mm after ET
= proceed to endocrine testing (blastocyst)

Optional supplementary progesterone

(vaginal, rectal, intramuscular
or subcutaneous)
Variation in time commenced

Figure 4. Natural cycle and modified natural cycle FER example cycle timelines. The timeline starts at day 1, which is the first day of the menstrual
period. Variation exists between clinics, particularly with regard to the methods used to determine the time of ovulation. ET = embryo transfer;
FER = frozen–thawed embryo replacement; hCG = human chorionic gonadotrophin; LH = luteinising hormone; USS = ultrasound scan.

Natural cycle FER avoids medication, which is costly and can
have adverse effects. However, the rate of cycle cancellation
associated with natural cycle FER is relatively high, with
estimates of around 8–15% versus 1–2% for medicated
FER.54,56 A cycle may be cancelled when no dominant follicle
is seen, the LH surge is not diagnosed, bleeding occurs or the
endometrium is of insufficient thickness.
There is debate regarding the most effective monitoring
strategy to detect ovulation. A common approach involves
ultrasound monitoring of the ovaries to identify a dominant
follicle, followed by blood and/or urine LH testing. Embryo
transfer is usually undertaken on day 6 or 7 after LH surge
for a blastocyst stage embryo.57 Consequently, the date of
embryo transfer is fixed in time relative to ovulation. This
can be inconvenient when managing clinical workflow,
particularly if a clinic is closed at weekends. Moreover,
identifying the LH surge represents a challenge. There is
variability in the profile of the LH surge between cycles, even
in the same woman;58,59 the rise in urine LH can lag behind
blood by a number of hours and urine monitoring kits have a
high false-negative rate.60,61 Consequently, some clinics also
perform regular ultrasound scans to confirm ovulation and
test for the rise in serum progesterone that follows luteinisation.
Modified natural cycle frozen–thawed
embryo replacement
An exogenous hCG trigger can be used to more accurately
define the time of ovulation in the ‘modified natural cycle’.

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 Frozen–thawed embryo replacement

Days 10–13
USS
Endometrial thickness ≥7 mm

Oral and/or transdermal estrogen

Progesterone (vaginal, rectal, IM or SC)
Day 2 Estrogen and
Once endometrium is ‘at criteria’ progesterone
progesterone can be continued to
commenced at any time ≥10 weeks of
gestation
Embryo transfer
on 5th or 6th day
of progesterone

Pituitary suppression
(to prevent endogenous surge of luteinising hormone causing luteinisation
and progesterone exposure)

1. A GnRH agonist (intranasal spray or daily SC injections can be administered for

around 3 weeks prior to commencing estrogen to downregulate the pituitary

2. Alternatively, a GnRH antagonist (daily SC injections) can be given during the

3. Alternatively, no supplementary pituitary suppression (on the basis that high

serum estrogen should provide pituitary suppression)

Figure 5. Hormone replacement (medicated) FER example cycle timeline. The cycle starts on day 2 of the menstrual period. Variation exists
between clinics, particularly with regard to the use of pituitary suppression, the route of estrogen and progesterone, and the criteria used to assess
the endometrium on ultrasound. FER = frozen–thawed embryo replacement; GnRH = gonadotrophin-releasing hormone; IM = intramuscular;
SC = subcutaneous; USS = ultrasound scan.

The dominant follicle is tracked until it is 16–20 mm in
diameter, after which an hCG injection is administered
(Figure 4). Retrospective data comparing hCG triggering
with endocrine monitoring in natural cycle FER are
conflicting,62–65 and only two small RCTs have made this
comparison.66,67 The first involved 124 women and was
stopped early because of a low pregnancy rate in the hCG
group.66 The second involved 60 women and demonstrated
no difference in clinical pregnancy or live-birth rates.67
Consequently, there remains debate as to which approach
is superior.
The benefit of supplementary luteal phase progesterone in
natural cycle FER is unclear. One RCT68 demonstrated a
higher live-birth rate in patients administering vaginal
progesterone from the evening of embryo transfer.
However, one RCT and several retrospective studies65,69–71
have demonstrated no benefit to supplementary progesterone
in modified natural cycle FER, with a large retrospective
analysis undertaken in 2016 showing no benefit in true
natural cycle FER.65 Despite limited evidence of benefit, there
does not appear to be a detrimental effect of supplementary
progesterone on pregnancy and live-birth rate.
Hormone replacement (medicated) frozen–thawed
embryo replacement
The process of medicated FER is outlined in Figure 5.
Medicated FER permits embryo transfer in women with
infrequent or no ovulation. It involves administration of oral
and/or subcutaneous estrogen to induce endometrial
proliferation. The endometrium is monitored via
ultrasound and once target criteria are achieved (after
approximately 2 weeks of estrogen), progesterone is
introduced to encourage endometrial decidualisation.
Embryo transfer is usually on the fifth or sixth day of

64 ª 2019 Royal College of Obstetricians and Gynaecologists


progesterone for blastocysts.57,72 However, optimal timing
may vary between individuals, with research continuing to
identify histological or genomic tests to determine the
personalised window of implantation.73–78
There is reasonable evidence that estrogen can be
continued for several weeks before the introduction of
progesterone in medicated FER with no adverse effect on
clinical pregnancy rate.79 Consequently, medicated FER offers
flexibility over timing of embryo transfer, which is
convenient for women and when managing clinic workflow.
During medicated FER it is imperative that the
endometrium is not exposed to endogenous progesterone,
which could shift the window of implantation. In theory, the
high dose of exogenous estrogen should prevent ovulation.
However, some protocols involve pituitary downregulation
through administration of a GnRH agonist, either
subcutaneously or intranasally, for around 3 weeks before
commencing estrogen. The benefit of this ‘pituitary
suppression’ is unknown, with only a small number of RCTs
addressing the issue.80–83 Given that GnRH agonists prolong
the medicated FER cycle and are associated with
hypoestrogenic adverse effects, an alternative is daily
subcutaneous GnRH antagonist injections given alongside
estrogen to block pituitary and ovarian activity directly. The
use of GnRH antagonist in medicated FER has been
insufficiently studied and the results of a continuing RCT
comparing medicated FER with and without GnRH antagonist
are keenly awaited (clinicaltrials.gov, NCT03763786).
Ovarian stimulation cycles
Frozen–thawed embryos can also be transferred as part of a
mild ovarian stimulation cycle. This offers patients with
ovulatory problems an alternative to standard hormone
replacement FER. Traditional ovulation induction regimens
involve low-dose gonadotrophin injections or clomifene. The
limited available evidence shows equivalent pregnancy rates
between gonadotrophin FER and both medicated and natural
cycle FER.84–86 However, gonadotrophin protocols are
complicated, involve intensive monitoring and carry a risk
of OHSS. Consequently, the use of gonadotrophin for FER is
uncommon. Similarly, clomifene is not widely used in FER,
as it may have an anti-estrogen effect on the endometrium
and has been associated with a thin endometrium with
abnormal subendometrial blood flow.55,87,88
There has been recent interest in the aromatase inhibitor
letrozole, which is used as an ovulation induction agent in
PCOS. Patients taking letrozole have increased endometrial
expression of integrin, a marker of endometrial receptivity,
suggesting that letrozole may aid implantation.87–90 Letrozole
FER requires fewer days of medication than medicated FER and
small retrospective studies suggest at least equivalent clinical
pregnancy rates.91–93 However, more research is required.
ª 2019 Royal College of Obstetricians and Gynaecologists
Noble and Child
Endometrial thickness in frozen–thawed
embryo replacement
The minimum endometrial thickness needed before FER is
controversial, with a cut-off of 7 mm often used on the basis
of meta-analysis data from fresh IVF cycles.94 However, in
an analysis of 768 medicated FER cycles,95 a higher
pregnancy rate was demonstrated with an endometrial
thickness of 9–14 mm compared with 7–8 mm. Others
have demonstrated a poor correlation between endometrial
thickness and outcome, instead favouring more complex
criteria involving endometrial pattern.96 However, these
more complex criteria can be difficult to translate into
routine clinical practice.
A 2018 analysis of more than 18 000 FERs from the
Canadian ART Registry97 demonstrated a reduction in
clinical pregnancy and live-birth rates with each millimetre
decrease in endometrial thickness below 7 mm. The
difference in live-birth rate between women with an
endometrial thickness of more than 7 mm and those with a
thickness of 6.0–6.9 mm was 4.6% (odds ratio 1.29, 95% CI
1.03–1.62). However, it is important to balance the decrease
in live-birth rate associated with thin endometrium against
the effect that recurrently cancelling cycles may have on the
cumulative chance of live birth over the long term. While it is
prudent to try different methods of endometrial preparation
in those with thin endometrium, in some an endometrial
thickness greater than 7 mm will be unachievable.
Calculation of estimated due date
The day of egg collection in fresh IVF is akin to ovulation in
the natural cycle, which occurs around 2 weeks after the first
day of the last menstrual period. Consequently, the
theoretical gestational age of a pregnancy at the time of
fresh or frozen embryo transfer is 2 weeks plus the age of the
embryo (in other words, 2 weeks and 5 days for a blastocyst).
The pregnancy test is normally undertaken 11 days after
blastocyst transfer, which is 4 weeks and 2 days of gestation.
Legal and ethical considerations
Under UK law the statutory maximum period an embryo
can be stored is 10 years. This can be extended to 55 years
for women likely to become prematurely infertile – e.g.
those requiring gonadotoxic therapy.98 NHS funding for
embryo storage varies widely across the UK.99 The private
cost of embryo storage is approximately £200–500 a year,
depending on the individual clinic. When patients cannot
afford storage fees, they may be forced to discard viable
embryos, denying them the opportunity to conceive. This
may be contrary to an individual’s moral or religious views,
with some considering it ethically unsound for the NHS to
cover the cost of embryo creation while refusing to fund
continuing storage.
65
 Frozen–thawed embryo replacement
A 2015 qualitative study100 that investigated the attitudes
of couples to frozen embryos found a wide variety of views,
with some conceptualising frozen embryos in scientific terms
such as ‘cells’, others functional terms such as ‘back up’ and
some using more emotive terms such as ‘life’ or ‘babies in
waiting’. When a person or couple have embryos remaining
in storage after completion of their family, they may have a
difficult decision to make regarding what to do with these
embryos. Options include discarding the embryos or
donating them for training, for research or to other patients.
Consent for use of cryopreserved embryos
When embryos are owned by two people, having been created
using their own or donor gametes, UK law permits the
freezing, storage and transfer of these embryos only with the
consent of both people (in the case of surrogacy consent of the
surrogate would also be required for transfer).98 This legal
situation was tested by Natalie Evans, who in 2007 lost a
4-year legal case to use embryos created with her former
partner.101 Ms Evans and her partner created six embryos
through IVF in advance of her undergoing bilateral
oophorectomy for ovarian cancer. However, after their
relationship broke down, Ms Evans’ partner withdrew his
consent to use the embryos. The European Court of Justice
ruled against Ms Evans’ and the embryos were discarded.
In another high-profile case, the father of a child born after
the father’s former partner forged his signature on a ‘consent to
thaw’ form before transfer of a frozen–thawed embryo sought
damages from the IVF clinic.102 Although the judge ruled in
favour of the IVF clinic, he recommended more robust consent
and identity checks at the time of embryo transfer.
Both of these cases illustrate the need for high-quality
counselling and consent-taking procedures when couples
create and freeze embryos together. In cases of fertility
preservation before fertility-compromising treatment, storing
of an individual’s gametes rather than embryos may be
preferable to prevent future withdrawal of consent.
Conclusion
The number and proportion of FER cycles undertaken in the
UK and worldwide has increased dramatically over recent
years. It is important for general obstetricians and
gynaecologists to be aware of this trend, as well as the
process of FER and the potential issues that may arise both
during the cycle and in any resulting pregnancy.
Disclosure of interests
The authors have no conflicts of interest to disclose.
Contribution to authorship
Both authors contributed to the article and approved the
final version.
66
Acknowledgements
The authors would like to thank the couple who consented to
the use of the photographs of their embryo and the
embryologist Caroline Ross for taking these images.
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ª 2019 Royal College of Obstetricians and Gynaecologists